Hospice Status Form and Instructions

Fax to the number listed on the form.

Appointing a Representative Form

Download this form to appoint someone to act on your behalf when requesting a coverage
determination. You can name a relative, friend, advocate, doctor, or anyone else
to act for you. Some other persons may already be authorized under state law to
act for you. If you want someone to act for you, then you and that person must sign
and date this form.

This website is intended to provide you with information about Medicare prescription drug coverage so you can make an informed decision about how Medicare Part D can help you manage your prescription drug costs. The International Brotherhood of Teamsters Voluntary Employee Benefits Trust is a PDP with a Medicare contract. Enrollment in TEAMStar Medicare Part D Prescription Drug Program (PDP) depends on contract renewal.